Presentation on theme: "Be Thou my Vision, O Lord of my heart; Naught be all else to me, save that Thou art. Thou my best Thought, by day or by night, Waking or sleeping, Thy."— Presentation transcript:
Example 82M acute stroke after gall bladder surgery. Can’t swallow, needs feeding tube to live.
Example 21M history brain tumor. Recurred after 15 years. Prolonged chemo and radiation therapy much of life.
Example 88M severe valve disease. Multiple hospitalizations for heart failure. Needs valve surgery, which would likely result in need for dialysis. Patient absolutely against dialysis. Some dementia, family wants procedure done.
Example 67M history heart attack/poor heart function. Resuscitated after cardiac arrest. Needs ventilator and strong IV meds to live. Brain functioning but damaged; no response to environment. Family wants to withdraw support.
Suggestions You need to decide these things for yourself You need to talk to your loved ones about these things ahead of time – what you want, what they want You need to communicate these things to a personal physician you trust, or find a new doctor Communicate to the hospital doctors
An advance directive is a document that outlines people’s preferences for medical care when, in the future, they are unable to communicate their wishes. It is particularly useful when someone is terminally ill, critically ill or has advanced Alzheimer’s disease. Advance directives give people a voice in their own medical decisions even after they have lost the ability to speak for themselves.
An adult age 18 or older is the only person who can make decisions for that adult. Wisconsin is NOT a “next of kin” or “family consent” state for adults. This means family members are not automatically authorized to make decisions for other family members. This includes spouses. Caveat: in emergency and some long-term care situations, if family present are in agreement, medical professionals will generally proceed with agreed upon treatment. In order for a person to legally complete an advance directive, he/she must have “decision-making capacity”, meaning that person: 1.Understands the situation 2.Knows what the options and consequences are 3.Can make a decision with understanding 4.Can communicate his/her decision
A living will contains written instructions from the patient (called the “declarant”) directly to the treating physician which directs the physician to refuse certain life sustaining procedures when the patient’s death is imminent due to: 1. a terminal condition 2. the patient being in a persistent vegetative state A living will does not apply to any other health care situation A living will does not appoint anyone to make health care decisions for anyone else. It is a directive meant for the physician. Living wills must be signed and dated by the patient as well as signed by two witnesses. Witnesses: Must be adults that are not related by blood, marriage or adoption to the patient, Must not have any claim to a portion of the patient’s estate, and Must not be directly financially responsible for the patient’s health care. A Power of Attorney for Health Care will also cover these situations.
People with early dementia or Alzheimer’s disease may still have decision-making capacity. They may be forgetful, but they continue to know what their values are and what they want to happen to them. A document that authorizes another person (called the “agent”) to make health care decisions for the person executing the document (called the “principal”) and directs the agent as to the principal’s wishes. The POA-HC may also name an alternative agent in case the primary agent is unable or unwilling to act as agent. IMPORTANT: the person you choose to be your agent will have full decision making authority once the POA-HC is activated. Although they are required to act in “good faith”, be sure you choose your agent carefully and make sure they understand your wishes. A POA-HC does not grant power over the principal’s finances. A separate document, a Power of Attorney for Finances, grants those rights.
IMPORTANT: the person you choose to be your agent will have full decision making authority once the POA-HC is activated. Although they are required to act in “good faith”, be sure you choose your agent carefully, and make sure they understand your wishes. And be sure they know you have chosen them to be your POA-HC! To be valid, a POA-HC must be: 1. In writing 2. Dated and signed by the principal or by an adult at the express direction and in the presence of the principal 3. Signed in the presence of two qualified witnesses Qualified witnesses are disinterested, unrelated, not directly financially responsible for the principal’s healthcare The agent being appointed in the POA-HC may not be a witness 4. Voluntarily executed 5. Contain certain notice language found in the state form or a specific statement by your lawyer
Once executed, the POA-HC goes “dormant” until it’s needed. When the principal becomes incapacitated, the POA-HC needs to be “activated” and then the agent begins making health care decisions on behalf of the principal. POA-HC does not go into effect (“become activated”) until: 1. Two physicians OR 2. One physician and one psychologist Who are not related to the principal and have no interest in the principal’s estate have physically examined the principal and “certify” that the he/she has become “incapacitated.” This certification must be then attached to the signed POA-HC. Incapacity means that a person is unable to “receive and evaluate information effectively or to communicate decisions to such an extent that the individual lacks the capacity to manage his or her own health care decisions.” Old age, eccentricity or physical disability are not enough to find incapacity. Incapacity can be temporary. A POA-HC can be activated and deactivated many times. Each activation requires the same determination of incapacity. Incapacity vs. Incompetence
In Wisconsin, certain actions may not be taken by an agent without specific authorization spelled out in the POA-HC: 1. Admission to a nursing home on a long term basis 2. Withholding/withdrawing feeding tubes 3. Health care decisions for a principal who is pregnant If the principal dies, the POA-HC dies with him or her. The POA-HC does not grant rights to settle the estate of the principal to the agent. POA-HC can be revoked by any of the following methods: 1.Destroying the POA-HC document 2.Executing a statement, in writing and signed and dated by the principal, that expresses the principal’s intent to revoke 3.Verbally expressing the principal’s intent to revoke in the presence of two witnesses 4.Executing a subsequent POA-HC
If an incapacitated person does not have a POAHC and has either no family or a family that cannot agree on their treatment, a guardian must be appointed to make decisions for them. Guardians are court-appointed Process through the courts is lengthy and expensive Person appointed as guardian may or may not be related to or know you and your wishes A document that authorizes another person (called the “agent”) to make health care decisions for the person executing the document (called the “principal”) and directs the agent as to the principal’s wishes Gives the agent specific or general powers over principal’s finances Takes effect at a time designated by the principal in the document – can be immediate or at a later date, while principal is competent or incompetent. Can be different or same person as POAHC
A “Do Not Resuscitate” or “DNR” is a request not to have CPR performed if your heart stops or if you stop breathing. A person may refuse CPR in the institutional setting such as hospitals and nursing homes by having his or her physician write such an order. Outside of an inpatient setting, Emergency Medical Technicans have a duty to revive him/her unless he/she is wearing a state-approved DNR bracelet. Plastic, free, signed by the doctor that signed the DNR, OR a metal Medic- Alert bracelet. An attending physician may issue a DNR order for a non-hospitalized patient only if all of the following apply: The individual is 18 years or older and Has a terminal condition or Has a medical condition such that if the individual were to suffer cardiac or pulmonary failure, resuscitation would be unsuccessful in restoring such function or the individual would suffer repeated failure within a short period before death; Has a medical condition such that resuscitation would cause significant physical pain or harm that would outweigh the possibility that resuscitation could restore function for an indefinite period of time. If a person has a written DNR order, but is not wearing a state-approved DNR bracelet, EMTs are required by law to begin life-saving efforts.
A DNR order can be revoked at any time by one of the following methods: 1.The patient expresses the desire to be resuscitated 2.The patient burns, cuts or otherwise destroys the DNR bracelet 3.The patient removes the DNR bracelet
Nuts and Bolts of a Power of Attorney for Health Care Karen Ruppier
Completing Advanced Directives/Power of Attorney for Health Care (POA HC) Objectives: Knowledge of End of Life, Advance Directives, POA HC document, Living Will How to choose POA HC agent Components to consider in creating AD/POA HC Creating a POA HC
Advance Directive: Declaration to Physician (Living Will)
Completing POA HC Choose POA HC agents Consider Advance Directives–biblical principals, quality of life, medical condition Discuss decisions with POA HC agent; use questionnaire Complete document; sign document in presence of two witnesses not related to you or your agents
Who should you choose as Healthcare POA agents? Is the person willing to accept the responsibility? Is the person able to make difficult decisions under stress and advocate for you? Does the person know your values and choices? Is this person able to deal with tough issues in a crisis? Can the person speak your wishes even if they do not agree with them?
Role of Agent Make sure that the agent you choose: Is entrusted to speak for the patient/principal Is involved in the discussion related to the patient/principal’s care Is willing and able to take the agent role Is willing and able to respect and honor the choices of the patient/principal
Spiritual Dimensions A very personal dimension of one’s life includes one’s faith. An appreciation of how your personal faith and biblical principals fits into the discussion on end-of-life care is important. An understanding of how your faith community stands on these issues may be beneficial. Contact your pastor, clergy or spiritual advisor and access other resources to answer questions, if appropriate.
End of Life Decision Choices to initiate life-sustaining treatment CPR Ventilator Support Kidney Dialysis Choices to withdraw or withhold life-sustaining treatment Feeding tubes, including stomach, nasogastric (placed down nose), intravenous Ventilator Support Choices related to comfort care Surgical procedures Palliation and pain management
How to begin to talk about Advance Directives/End of Life Care There may be a time I will not be able to express my wishes about end of life, so I would like to take this time to talk you … I want to talk with you about my advance directives so if/when you are asked what my wishes are you will know… I know it is not easy talking about advance directives but the more you know my wishes, the fewer decisions you need to make without knowing what I would want… I would like to give you some information to help you understand my considerations about end of life decisions…
How to begin to talk about Advance Directives/End of Life Care You are important, and so are your wishes… We want to make sure we take good care of you… I would like to give you some information to help you with your considerations about end of life decisions…what are your thoughts? There may be a point in time when you cannot talk about your wishes, so let us talk about this now…
I do not know all about you that I need to know to take care of you as you would like… We do not know your preferences and goals. If you cannot tell us in advance, we could do too little or too much, and that is not necessarily serving your needs…
Once POA HC Completed What do I do once my AD has been completed? Give a copy to: Primary physician Hospital upon admission Agents Lawyer Any health care facility or agency that you use Car when traveling Communicate placement of document in own home